10.05 Ring Removal

Presentation

A ring has become tight on the patient's finger after an
injury (usually a sprain of the proximal interphalangeal or
PIP joint) or after some other cause of swelling, such as a
local reaction to a bee sting. Sometimes, tight-fitting
rings obstruct lymphatic drainage, causing swelling and
further constriction. The patient usually wants the ring
removed even if it requires cutting it off, but occasionally
a patient has a very personal attachment to the ring and
objects to its cutting or removal.

What to do:

Limit further swelling by applying ice and elevating the
extremity above the level of the heart.

When a fracture is suspected, order appropriate x rays
either before or after removing the ring.

With substantial injuries, a digital or metacarpal block
might be necessary to allow for the comfortable removal of
the ring.

Usually, lubrication with soap and water along with
proximal traction on the skin beneath the ring is enough to
help you twist the ring off the finger.

When the ring is too tight to twist off this way,
exsanguinate the finger by applying a tightly wrapped
spiral of Penrose drain or flat rubber phlebotomy
tourniquet tape around the exposed portion of the finger,
elevate the hand above the head, wait five minutes and then
apply a BP cuff inflated to 200-280 mm Hg as a tourniquet around
the upper arm. Wrap the cuff with cotton cast padding to keep the Velcro conection from separating under high pressure, and clamp the tubing to prevent any slow air leak. Remove the tight rubber wrapping from the finger and,
leaving the tourniquet in place, again attempt to twist the
ring off using soap and water for lubrication.

If the ring is still too tight or there is too much pain to
allow for the above techniques, a ring cutter can be used
to cut through a narrow ring band. Have the patient grasp a rolled elastic bandage to stabilize the hand and elevate the dorsal side of the ring so it is easier to insert the ring cutter. Once there is one cut completely through the ring, bend the ring apart with
pliers placed on either side of this break to allow
removal.

If the band is wide or made of hard metal, it will be
much easier to cut out a 5mm wedge from the ring using an
orthopedic pin cutter. Then take a cast spreader, place it
in the slot left by the removal of the wedge and spread the
ring open. Alternatively, two cuts may be made on opposite
sides of the ring, allowing it to be removed in halves.

Another useful device for removing constricting metal
bands is the Dremel Moto-tool with its sharp-edged grinder
attachment. Protect the underlying skin with a heat-resistant shield.

Another technique which tends to be rather time-consuming
and only moderately effective (but one that can be readily
attempted in the field) is the coiled string technique.
Slip the end of a string (kite string is good) under the
ring and wind a tight single-layer coil down the finger,
compressing the swelling as you go. Pull up on the end of
the string under the ring, then slide and wiggle the ring
down over the coil.

Another string removal technique is to pull a length of string under the ring and tie it into a large loop that you can place around your own wrist. This will allow you to apply traction and slide the string around the circumference of the ring (allowing skin to slip beneath the ring) while you pull the ring off using lubricant as above.

Teach patients how to avoid the vicious cycle of a
tourniquet effect by promptly removing rings from injured
fingers.

What not to do:

When a patient is expected to have transient swelling of
the hand or finger without evidence of vascular
compromise, and he requests that the ring not be removed,
do not be insistent that you must cut the ring off. If the
patient is at all responsible, he can be warned of
vascular compromise (pallor, cyanosis, or pain) and
instructed to keep his hand elevated and apply cool
compresses. He should then be made to understand that he
is to return for further care if the circulation does
become compromised because of the possible risk of losing
his finger. Be understanding and document the patient's
request and your directions.

Discussion:

The constricting effects of a circumferential foreign body
can lead to obstruction of lymphatic drainage, which in turn
leads to more swelling and further constriction, until
venous and eventually arterial circulation is compromised.
If you believe that these consequences are inevitable you
should be quite direct with the patient about having the
ring removed.